"Holliday et al (3) conducted an anonymous survey in which medical students applying in Radiation Oncology reported experiencing “behaviors that conflict with written NRMP policies, either during or after interviews” (3) . Of those who responded, alarmingly high percentages perceived that the system can be “gamed” through actions ranging from a wink and a nod, embellished thank you notes and advocacy phone calls, all the way to overt promises and declarations of interest (the potentially disingenuous nature of which is disturbing in itself). Radiation Oncology is fortunate to attract über-competitive “top-seed” candidates with credentials that confer prestige and promise to our specialty's future (4) , but, it being such a competitive field, most candidates are applying to dozens of programs. Both programs and candidates have sought a way through the morass by essentially “prearranging” matches ahead of the Match deadline. Programs seek affirmation that the applicant will rank them first, and applicants, with the stress of an overwhelming process, are tying themselves into knots trying to let all the programs at which they interview feel that they will be ranking them number one. Many candidates have complicated decisions to make about their lives and genuinely do not know their program ranking until the last minute, but the pressure is on to “show their hand” (5) . First-year residents, when asked what it was that they found most stressful about the process, describe the subtle pressure that programs put them under “to declare” them as top of the list. The anxiety when applicants are obligated to “play the game” is immense, even cruel. An implicit requirement to declare a first-choice program may have significant practical consequences: an excellent applicant who declared a “first choice,” yet narrowly failed to match at that program, may have plummeted down the rank list of other programs unwilling to “waste” a high slot on him or her. Applicants may not be truthful in their post-interview communications (for example, telling multiple programs they are the first choice)—behavior that can never be condoned, but which the new norms incentivize. The report by Holliday et al confirms what we knew in our hearts: that the pendulum has indeed, insidiously, swung in this direction and that these behaviors are now regarded as the new normal rather than in any way deviant.
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"From the perspective of the applicants, Jena et al (10) surveyed senior medical students at 7 US medical schools regarding post-interview communications with programs and uncovered that more than 85% of respondents reported communicating with programs, with nearly 60% notifying more than one program that they would rank it highly. Furthermore, students reported that programs indicated that they would be “ranked to match,” “ranked highly” (52.8%), or other similar suggestive euphemisms. Most worrisome is that nearly a quarter of applicants admitted that they altered their rank order list on the basis of these programmatic communications, and 1 in 5 who ranked programs according to these promises did not match at that program, despite ranking it first.